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The objective was to explore the relationship between the cortisol awakening response (CAR) and the metabolic syndrome (MetS) as defined by the National Cholesterol Education Program criteria. The final study sample consisted of 91 women (14 with MetS) and 84 men (15 with MetS), aged 45 to 70 years, from a general population sample. The only exclusion criteria were no consent, pregnancy, or insufficient cortisol testing. On the day of measurement (weekday), salivary cortisol was sampled at awakening and 15 minutes after awakening. Relative CAR (CAR%) and the MetS were the main variables studied. Results showed that, in women with the MetS, cortisol at awakening was significantly lower (mean, 8.92 vs 12.33 nmol/L; P = .05) and the CAR was significantly higher (91.4% vs 36.5%, P < .001) than in women without the syndrome. Significant difference in the relative CAR was also present between men and women with MetS (38.5% and 91.4%, respectively; P = .02). No difference was seen in the awakening response comparing men with and without the MetS. In a regression model, the response to awakening was dependent on the MetS in women (F1,89 = 13.19, P < .001); but the model was not significant in men. Furthermore, the awakening response was associated with more depressive symptoms in women (F1,80 = 8.12, P = .01) and with weekday/weekend cortisol sampling in men (F1,82 = 4.63, P = .03). The association between the relative CAR and the MetS remained significant but somewhat attenuated after adjusting for depressive symptoms (P = .01). Results indicate a sex difference in the CAR% in the presence of the MetS independent of depressive symptoms, a known correlate of the MetS.

Migraine is a disabling neurological disorder with high prevalence, the clinical manifestations of which are highly dependent on stress.

The overall theme of the present thesis was to address aspects of stress in migraine. A multimodal behavioral treatment (MBT) program was developed specifically designed for migraine and focusing on stress as a trigger and an intervention was performed using this Internet-administered program. Migraine symptoms were followed via an Internet administered diary and questionnaires were answered at regular intervals during the 11-month study period.

The thesis is based on four papers:In Paper I, life events and current stress, personality traits, and gender were studied cross-sectionally in 106 women and 44 men with migraine, who suffered at least two attacks a month at inclusion. Paper II describes a randomized controlled trial of the MBT program performed on 58 women and 25 men recruited from participants of the study described in Paper I. In the MBT study participants were randomized into one control group and two MBT groups, one of which received hand massage as part of the treatment. In Paper III, complete migraine drug use and changes in use and in drug efficacy during the MBT program were studied. In Paper IV, the salivary cortisol levels of MBT participants were evaluated as a biological stress marker.

The MBT program proved effective in decreasing migraine headache; it was feasible and there was low attrition. Moreover, MBT resulted in decreased migraine drug use and increased drug efficacy, but had no discernible effects on salivary cortisol profiles. No effect of hand massage on migraine headache frequency was seen. Personality trait profiling revealed high scores for the neuroticism factor. Stress susceptibility was the single most aberrant personality trait and correlated highly with the reported level of current stress and with experienced negative life events.

Gender differences included higher scores for women on trait anxiety, negative life events, depressive mood, anxiety, tension type headache, use of triptans, and efficacy of analgesics, whereas men displayed higher use of analgesics.

In conclusion, the efficacy and low attrition associated with the present MBT program appears promising and timely with regard to the development of better and more accessible migraine treatment. Stress susceptibility, gender, negative life events and psychosomatic comorbidity are important factors to consider in relation to the care of persons with migraine.

4. Stress in migraine

Hedborg, Kerstin

et al.

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Medical science.

Background and aim. The individual's experiences of stress as well as constitutional factors, including high neuroticism and female gender, are known determinants for migraine. The present aim was to further elucidate factors of personality and stress, including life events, in relation to gender in migraine. Methods. A cross-sectional study was performed on 150 persons, 106 women and 44 men, suffering from at least two migraine attacks a month. All obtained a doctor-defined migraine diagnosis based on a structured face-to-face interview concerning their health situation and current and prior stress. All of them also answered validated questionnaires regarding personality traits (SSP), life events, and perceived ongoing stress. Results. The personality trait inventory showed high mean scores for stress susceptibility and low mean scores for aggressiveness and adventure seeking, both for women and for men, as well as high mean scores for psychic and somatic anxiety in women. Stress susceptibility, the overall most deviant trait, correlated strikingly with current level of stress in both sexes. In women, stress susceptibility also correlated strongly with experiences of negative life events. Tension-type headache, anxiety, and depression were approximately twice as prevalent in women compared to men. Conclusions. The present study confirms previous research, showing that stress is an important factor in migraine. Stress susceptibility, life events, and concomitant psychosomatic illnesses should be considered important when evaluating individuals with migraine, and gender aspects need to be taken into account.

Objective: To evaluate salivary cortisol as a biological stress marker in migraine and how the different measurements used were affected during the course of a multimodal stress treatment program.

Methods: Saliva samples were collected at four predetermined time points of the day at inclusion, at mid-treatment, and at treatment conclusion during the course of a controlled Internet-administered multimodal behavioral treatment (MBT) intervention focusing on stress. Seventy-six participants (52 women/24 men) reporting at least two migraine attacks a month at inclusion were enrolled. The following four measurements of salivary cortisol as putative stress markers were used: aberrant Awakening Cortisol Response (ACR; < 50% or > 160% or < 2.5 nmol/L), low daytime profiles (all values <13 nmol/L), a low daytime value(s) (< 2.5 nmol/L; excluding the bedtime value), a high bedtime value (> 6 nmol/L), and a summarizing cortisol “index”. In a multivariate model these outcome measurements were compared to the following parameters: MBT treatment time, headache level, gender, stress susceptibility, negative life events, quality of life, depressive mood, physical activity, and body mass index − chosen as independent parameters related to stress.

Results: During the course of the MBT study the rate of aberrant relative ACR (< 50% or > 160%) was high with a range of 59 to 83 percent. No differences in aberrant cortisol profiles (ACR and low daytime profile) were detected as a function of: treatment (vs. control), degree of headache improvement, gender, or body mass index. With regard to single cortisol values (day- or bedtime), the number of high bedtime values increased and the number of low daytime values decreased significantly with time for participants in MBT when compared with controls, thus providing ambiguous data on change in stress responses as a function of the intervention. Low daytime profiles correlated with stress susceptibility. Experience of strongly negative life events during childhood and adolescence correlated with low daytime values and a higher cortisol “index”. However, the inverse relationship was found for strongly negative life events that had occurred during adulthood. Increased depressive mood according to MADRS-S scores was significantly associated with aberrant ACR.

Conclusions: The great variations in salivary cortisol profiles seen here demonstrate the complexity of cortisol regulation and, hence, underscore the difficulty of using measurements of salivary cortisol as stress markers in migraine. Although the intervention showed no consistent effect on cortisol levels, data need to be cautiously interpreted. Cortisol findings relating to stress susceptibility and life events during childhood/adolescence may be of particular interest for further study.

6. Multimodal behavioral treatment of migraine

Hedborg, Kerstin

et al.

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Medical science.

Introduction. Multimodal approaches in behavioral treatment have gained recent interest, with proven efficacy for migraine. The utility of the Internet has been demonstrated for behavioral treatment of headache disorders, but not specifically for migraine. The aim of the study was to develop and evaluate an Internet-based multimodal behavior treatment (MBT) program for migraine and to test hand massage treatment as an adjunct. Methods. Eighty-three adults, 58 women and 25 men, with at least two migraine attacks a month were recruited via advertisements. An MBT program aiming at improvements in life-style and stress coping was developed for this study and, together with a diary, adapted for use over the Internet. Participants were randomized to MBT with and without hand massage and to a control group, and were followed for 11 months. Questionnaires addressing issues of quality of life (PQ23) and depressive symptoms (MADRS-S) were used. Results. A 50%, or greater, reduction in migraine frequency was found in 40% and 42% of participants of the two groups receiving MBT (with and without hand massage, respectively), who statistically were significantly more improved than participants in the control group. No effect of hand massage was detected, and gender did not show any independent contribution to the effect in a multivariate analysis. Conclusions. MBT administered over the Internet appears feasible and effective in the treatment of migraine, but no effect of hand massage was found. For increased knowledge on long-term effects and the modes of action of the present MBT program, further studies are needed.

Objectives: To characterize overall drug use in migraine in conjunction with multimodal behavioral treatment (MBT). Methods: Seventy-six adults reporting at least two monthly migraine attacks underwent a randomized, controlled, 24-week MBT intervention. Migraine drugs and symptoms were registered in an Internet-based diary. Results: During 4256 days of baseline registration, 859 drug doses were taken during 655 of the 856 days with migraine headache. Triptans and analgesics constituted 56.7 and 38.3% of all doses with efficacy ratios of 0.41 and 0.20, respectively. Men displayed significantly lower drug efficacy (p = 0.001), and used triptans significantly less (p < 0.001) and analgesics significantly more (p < 0.001) than women. At the end of the MBT, total drug consumption decreased by 22% (p = 0.029), corresponding to 27% fewer days with migraine headache. Drug efficacy increased during MBT from 0.30 to 0.52 (p < 0.001), mainly explained by an increased proportion of mild attacks, which also was the attack category that displayed the largest increase in drug efficacy. Conclusions: Triptans were the most used and efficient drugs. MBT led to decreased and more efficient drug consumption. Men used triptans less frequently.

Creation of new knowledge is mainly accomplished by students themselves. The Case Method uses cases from real life to inspire students to actively seek knowledge, which they discuss in structured seminars in which the teacher plays an active role. The effectiveness of case-based learning in health professional education has recently been positive evaluated in a systematic review. With the aim to understand more about how students learn, focusing on case seminars, we asked nursing students about their learning experiences.

Sixty nine students, who had been participating in case seminars in cardiology during their second year of a Swedish three-year Bachelor of Science in Nursing programme, gave us their written narratives and data were analysed with the method content analysis.

The results of the analysis of the students’ learning experiences will be presented in detail and include descriptions of learning through discussions, an interest in other students’ solutions to problems and the importance of confirming one’s own knowledge. Also the structure, involving pre-prepared cases and writing on the white board and supervision in an open atmosphere seem to enable the learning and everyone to participate. A theme of how the Case Method opens doors to deeper understanding was identified as a main thread running through the codes and categories. To support our analyses we presented the results to the students one year later, asking for their views. All students present (62/69) recognized our descriptions of learning in case seminars to a great or very great degree.

Our conclusion is that the Case Method seems to involve nursing students in a way that deepens their understanding and we believe our findings will be of interest to other teachers. The study’s strengths and weaknesses and the possibilities of case seminars in nursing education are topics I look forward to discuss with my colleges at the Nordic Forum for Nurse Educators 2013.

9. Seminariet i högre utbildning – Seminariet på tavlan

Hofsten, Anna

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Medical science.

The Case Method is a teaching method in which cases from real life inspire students to actively seek knowledge that they discuss in seminars. During seminars, different solutions and ideas are written in a structured way on the white board. Hofsten (2010) described how case seminars in cardiology help nursing students share knowledge and identify possible ways of dealing with patients.

Summary of work

To deepen the understanding of learning in case seminars, we asked students in a very different educational context, psychiatric care, about their experiences. Written narratives from 44 nursing students were analyzed using a content analysis.

Summary of results

The students described the importance of different perspectives and of seeing a context and of learning in a climate that promotes discussions; they felt that the overview on the white board encouraged students to participate. Different categories and the preliminary themes To reflect on thoughts, To give and take, and To see what is said are shown in Figure 1. When we presented these results to the students, most reported recognizing our description of learning situation to a great or very great degree; see Figure 2.

Conclusions

The Case Method seems to involve students in a way that deepens their understanding and this effect seems to be independent of subject or teacher

12. Case seminars open doors to deeper understanding

Hofsten, Anna

et al.

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Medical science.

Gustafsson, Christina

University of Gävle, Faculty of Education and Business Studies, Department of Culture Studies, Religious Studies and Educational Sciences, Curriculum studies.

Häggström, Elisabeth

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Nursing science.

The Case Method is a teaching method in which cases from real life inspire students to actively seek knowledge that they discuss in structured seminars. Caseseminars in health education have been evaluated, compared and discussed, but descriptions that can help us understand how students learn in the seminars have not previously been published. In a Swedish nursing programme, where caseseminars have been used for several years, students were asked to write about their experiences of learning in the seminars. The aim of the present study was to describe this learning process from the students' point of view.

METHOD:

Written data were analysed using content analysis.

FINDINGS:

A theme concerning how the Case Method opens doors to deeperunderstanding was identified as a thread running through different codes and categories. Students described the importance of new perspectives and their wish to participate in discussions with other students. The students indicated that the structure, which involved pre-prepared cases and writing on the white board, positioned their own knowledge in a wider context and that the learning atmosphere enabled everyone to participate.

CONCLUSIONS:

The Case Method seems to involve students in a way that deepens their understanding and critical thinking.

13. Alternating large group seminars using the white board with small group discussions helps students be active and reflective

Hofsten, Anna

et al.

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Medical science.

Häggström, Elisabeth

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Nursing science. Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.

Discussion and reflection are important in university education, and in healthcare education patient cases are commonly used for this purpose. Learning in case seminars has recently been the topic of a systematic BEME review, which called for more qualitative research on how students learn and how much structure is required (1).

Summary of work

The number of students in healthcare education is increasing, and case seminars can involve as many as twenty students. How can we increase students’ opportunities for reflection? To address this question, we alternated large group with small group (three students) discussion approximately four times during a case. Large group discussion including white board notes was unaltered. To understand more about how students learn, we asked them to describe their learning in these kinds of seminars. Written data were collected in September 2013 from 68/80 students in a Swedish nursing program with case seminars. The narratives were analyzed using latent qualitative content analysis (2).

Summary of results

Three themes describing how students learn were identified in the analysis: Being active, Being part of a discussion and Seeing new problems and solutions. The analysis with examples of quotations will be presented at the conference.

Conclusions

In the small group, students were able to test ideas and build self-confidence, allowing them to act as problem-solvers in the large group discussion. Alternating large group seminars using the white board with small group discussions helps students be active and reflective and allows larger numbers of students per seminar.

14. Case seminars open doors to deeper understanding

Hofsten, Anna

et al.

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Medical science.

Häggström, Elisabeth

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Nursing science.

Introduction: Creation of new knowledge is mainly accomplished by students themselves, and the main task of teachers in higher education is thus to facilitate this learning process (Ramsden 2003). The Case Method is a teaching method in which cases from real life inspire students to actively seek knowledge to be discussed in structured seminars. In the seminars, the problem-solving process is important and the aim of the seminar discussion is to consider different solutions and identify possible ways of dealing with the situation. Case seminars in health education have been evaluated and discussed, but descriptions that can help us understand how students learn in the seminars have not previously been published. In a Swedish nursing programme, where case seminars have been used in teaching cardiovascular diseases for several years, students were asked to describe how the case seminars had helped them in their learning and what had been troublesome with the seminars, and 69/72 did. The aim of the present study was to describe this learning process from the students’ point of view.

Methods: Written data were analyzed using content analysis, a process of organizing and integrating qualitative information into themes, categories and codes. All quotations were read and commented on by the three authors, but the analysis was made by two of the authors in collaboration.

Results: A theme concerning how the Case Method opens doors to deeper understanding was identified as a thread running through different codes and categories. Students described the importance of new perspectives and their wish to participate in discussions with other students. The structure, which involved pre-prepared cases and writing on the white board, positioned the students’ own knowledge in a wider context and the learning atmosphere seemed to enable everyone to participate in the discussions (Hofsten et al 2009).

Discussion: The interest in reflective discussions, other students’ points of view and solutions to the cases indicate a deep approach to learning (Ramsden 2003). Two years later the findings were presented to the students who participated in the study. All students agreed much or very much to the analysis presented.

Conclusion: The Case Method seems to involve students in a way that deepens their understanding and critical thinking.

Creation of new knowledge is mainly accomplished by students themselves, and the main task of teachers in higher education is thus to facilitate this learning process. The Case Method is a teaching method in which cases from real life inspire students to actively seek knowledge that they discuss in structured seminars. Case seminars in health education have been evaluated, compared and discussed, but descriptions that can help us understand how students learn in the seminars have not previously been published. In a Swedish nursing programme, where case seminars have been used in teaching cardiovascular diseases for several years, students were asked to freely write down answers to three open questions concerning how the case seminars had helped them in their learning,what had been troublesome with the seminars, and whether they had any other comments on the seminars. The aim of the present study was to describe this learning process from the students’ point of view.

Methods

Written data were analyzed using content analysis, which is a process of organizing and integrating qualitative information into themes, categories and codes.

Findings

A theme concerning how the Case Method opens doors to deeper understanding was identified as a thread running through different codes and categories. Students described the importance of new perspectives and their wish to participate in discussions with other students. The structure, which involved pre-prepared cases and writing on the white board, seemed to position the students’ own knowledge in a wider context.This interest in reflective discussions andother students’ different opinions indicate a deep approach to learning. To see if the findings reflected the participants ́ voice, the analysis with quotations, codes, categories and a theme was presented two years later to 62/69 students participating in the study. In a questionnaire after the presentation all agreed much or very much with the findings presented. To conclude the Case Method seems to involve students in a way that deepens their understanding and critical thinking.

Gastrointestinal symptoms and lifestyle change over time. The data from this 18-year longitudinal study are intended to further elucidate the long-term natural course of functional gastrointestinal (GI) symptoms and possible influencing factors.

Aim

The aim of this study was to evaluate the correlation between lifestyle factors over time by reassessing symptom profiles in patients who presented with GI symptoms in 1990.

Method

The study population comprises a subset of individuals enrolled in the Swedish Dyspepsia Study, which commenced in 1990. In 1990, each participant in the Swedish Dyspepsia Study underwent physical assessment and completed a computer-based questionnaire on eight GI symptoms and lifestyle factors. An identical questionnaire was completed in 2008.

The results indicated that the lifestyle changes in the studied population followed the same

pattern as seen in the general population, and changes in lifestyle factors may have an impact on GI symptoms and may guide symptom management in the patient, all in order to reduce personal suffering and healthcare costs in the form of fewer visits to the doctor and lower numbers of drug prescriptions.

Aim. The aim of this study was to describe the complementary and alternative medicine methods most commonly used to alleviate symptom distress in persons with functional gastrointestinal disorders. Background. People with functional gastrointestinal disorders face many challenges in their everyday lives, and each individual has his/her own way of dealing with this illness. The experience of illness often leads persons with functional gastrointestinal disorders to complementary and alternative medicine as a viable healthcare choice. Design. Quantitative and describing design. Method. A study-specific complementary and alternative medicine questionnaire was used, including questions about complementary and alternative medicine methods used and the perceived effects of each method. Efficacy assessments for each method were preventive effect, partial symptom relief, total symptom relief or no effect. Results. A total of 137 persons with functional gastrointestinal disorders answered the questionnaire, 62% (n = 85) women and 38% (n = 52) men. A total of 28 different complementary and alternative medicine methods were identified and grouped into four categories: nutritional, drug/biological, psychological activity and physical activity. All persons had tried at least one method, and most methods provided partial symptom relief. Conclusion. Persons with functional gastrointestinal disorders commonly use complementary and alternative medicine methods to alleviate symptoms. Nurses have a unique opportunity to expand their roles in this group of patients. Relevance to clinical practice. Increased knowledge of complementary and alternative medicine practices would enable a more comprehensive patient assessment and a better plan for meaningful interventions that meet the needs of individual patients.

Background: The lack of adherence to drug therapy is a major problem; it can contribute to significant deterioration of disease and increased health-care costs. Improving medication adherence is a big challenge; there is no simple solution to the problem. It is thus essential to improve our knowledge of non-adherence (NA) and its causes.

Aims: The aims of the thesis were to study the influence of gender and psychological distress on self-reported, intentional and unintentional non-adherent behaviour, and to investigate the reasons for NA.

Methods: A population-based study that included a postal questionnaire was carried out in a cross-section of the general Swedish population (n=7,985, aged 18-84 years). The response rate was 61.1% (n=4,875) and current prescription drug use was reported by 2,802 participants. The questionnaire covered use of prescription drugs, NA to the drug regimens, reasons for NA, economic status, attitudes to drugs, and the presence of somatic or mental problems, and also included the Hospital Anxiety and Depression Scale questionnaire.

Results: The results showed differences in various self-reported non-adherent behaviour patterns and reasons for NA between the genders. In most cases, these remained after controlling for confounders such as socioeconomic factors and attitudes to drugs that are known to differ between women and men. Associations were also found between symptoms of anxiety and/or depression and the presence of intentional or unintentional non-adherent behaviour (with a stronger average association for intentional NA), and between anxiety/depression and some of the reasons given for NA, e.g. adverse drug reactions (ADRs).

Conclusions: Although it was not possible to confirm causal relationships, this thesis emphasises the effects of gender and psychological distress on NA. In summary, both gender and anxiety and/or depression influenced non-adherent behaviour and the reasons given for NA. For instance, ADRs seemed to influence the decision not to take the drug as prescribed, especially among women and participants under psychological distress. It is suggested that a deep understanding of the causes of NA and of the impact of gender and psychological distress on the outcomes would help those aiming to improve adherence to prescribed medication.

26. The influence of symptoms of anxiety and depression on medication nonadherence and its causes

Thunander Sundbom, Lena

et al.

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Medical science.

Purpose: The purpose of this study was to evaluate the associations between self-reported symptoms of anxiety and/or depression, nonadherent (NA) behaviors, and reasons for NA to medication regimens.

Methods: A population based cross-sectional study with questionnaire was performed in the general Swedish population. The participants were 2,802 prescription drug users aged 18–84 years. The questionnaire covered use of prescription drugs, symptoms of anxiety and/or depression, based on the Hospital Anxiety and Depression Scale (HADS), various NA behavior types, intentional and unintentional, and various reasons for NA.

Results: Symptoms of anxiety and depression, independently and in combination, were associated with unintentional and intentional NA, with a stronger association with intentional NA. Regarding the reasons given for NA, for example anxiety, independently or in combination with depression, was associated with a fear of developing adverse drug reactions (ADRs). Depression, independently or in combination with anxiety, on the other hand, was associated with the actual development of ADRs.

Conclusion: A cross-sectional design such as this does not allow assessment of causality derived from the results. However, the results indicate that patients experiencing symptoms of psychological distress are at increased risk of NA, especially intentional NA, and could therefore benefit from extra attention from the health care professional. Patients with symptoms of anxiety and/or depression should be identified and monitored for the development and/or fear of ADRs, in order to improve adherence to medication regimens.

Objectives: The aim of the present study was to analyse gender differences in self-reported non-adherence (NA) to prescribed medication in the Swedish general population. We aimed to study unintentional and intentional NA as well as the reasons given for NA.

Methods: A questionnaire was mailed to a cross-sectional, random, national sample of people aged 18-84 years in Sweden (n=7985). The response rate was 61.1% (n=4875). The questionnaire covered use of prescription drugs, NA behaviour and reasons for NA.

Results: Use of prescription drugs was reported by 59.5% (n=2802) of the participants, and 66.4% (n=1860) of these participants did not adhere to the prescribed regimen. No overall gender differences in reporting NA were found. However, when analysing the various types of NA behaviour and the reasons for NA, different gender patterns emerged. Men were more likely to report forgetting [OR 0.77 (95% CI 0.65:0.92)], changing the dosage [OR 0.64 (95% CI 0.52:0.79)] and that they had recovered [14.3%, (OR 0.71 (95% CI 0.56:0.90)] as a reason. In contrast, more women than men reported filling the prescription but not taking the drug [OR 1.25 (95% CI 1.02:1.54)] and reported the development of adverse drug reactions (ADRs) [OR 1.89 (95% CI 1.37:2.59)] as a reason more commonly. The gender differences remained, in most cases, after controlling for confounders such as age, socioeconomic factors, medical problems and attitudes toward drugs.

Conclusions: Women and men have different patterns of NA behaviour and different reasons for NA. Therefore, if adherence is to be improved, a wide knowledge of all the reasons for NA is required, along with an understanding of the impact of gender on the outcomes.

28. Hematologiutbildning för sjuksköterskor

Westergren, Eva

University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, Medical science.